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BlueChoice HMO Referral Bronze 8250 Med Ded 25 Dent Ded Virtual Connect Plus
Plan Summary
Plan Type HMO
Metal Level Bronze
Office Visit for Primary Doctor
Find Doctors 		Office/Non-hospital: Virtual Connect Plus through selected providers, including Closeknit - No charge* no deductible (carefirst.com/virtualconnect) All other providers - $55 copay, no deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Office Visit for Specialist Office/Non-hospital: $65 after deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Office Visit for Other Practitioner (Nurse, Physician Assistant) Office/Non-hospital: Virtual Connect Plus through selected providers, including Closeknit - No charge* no deductible (carefirst.com/virtualconnect) All other providers - $55 copay, no deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Annual Deductible Individual: $8,250
This deductible does not apply to preventive services, primary care office visits, urgent care visits, generic drugs and other services as noted.
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Coinsurance 40%
Retail Prescription Drugs Non-Maintenance Drugs: Up to a 30-Day Supply;
Preventive Drugs: No charge, no deductible;
Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible;
Non-Preferred Brand Insulin: 40% Coinsurance after deductible up to a $30 max;

Generic Drugs: $25, no deductible;
Preferred Brand Drugs: 40% Coinsurance after deductible;
Non-Preferred Brand Drugs: 40% Coinsurance after deductible

Specialty Drugs: Up to a 30-day supply only. Available only through mail order;
Preferred Specialty Drugs: 40% Coinsurance after deductible up to a $100 max;
Non-Preferred Specialty Drugs: 40% Coinsurance after deductible up to a $150 max

Maintenance Drugs: Up to a 90-day supply at 2 times the 30-day copay. Available for generic and brand name drugs through retail locations and mail order.
Annual Out-of-Pocket Limit Individual: $10,150
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Emergency Care Only. Coverage available in accordance with contract terms. Claims subject to review. 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam no charge, no deductible
Periodic OB-GYN Exam no charge, no deductible
Well Baby Care no charge, no deductible
Emergency and Urgent Care
Emergency Room Hospital charge: 40% coinsurance after deductible;
Physician charge: 40% coinsurance after deductible
Emergency Ambulance Services 40% coinsurance after deductible
Urgent Care Facility $85 copay, no deductible
Prescription Drug Coverage
Retail Prescription Drugs Non-Maintenance Drugs: Up to a 30-Day Supply;
Preventive Drugs: No charge, no deductible;
Diabetic Supplies and Preferred Brand Insulin: No charge, no deductible;
Non-Preferred Brand Insulin: 40% Coinsurance after deductible up to a $30 max;

Generic Drugs: $25, no deductible;
Preferred Brand Drugs: 40% Coinsurance after deductible;
Non-Preferred Brand Drugs: 40% Coinsurance after deductible

Specialty Drugs: Up to a 30-day supply only. Available only through mail order;
Preferred Specialty Drugs: 40% Coinsurance after deductible up to a $100 max;
Non-Preferred Specialty Drugs: 40% Coinsurance after deductible up to a $150 max

Maintenance Drugs: Up to a 90-day supply at 2 times the 30-day copay. Available for generic and brand name drugs through retail locations and mail order.
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Surgical Center/Non-Hospital: 40% coinsurance after deductible;
Hospital: 50% coinsurance after deductible; Additional physician fees may apply
Outpatient Lab/X-Ray Lab (LabCorp Only): 40% coinsurance after deductible;
Lab (Outpatient Hospital): 40% coinsurance after deductible;
X-ray (Office/non-hospital): 40% coinsurance after deductible;
X-ray (Outpatient Hospital): 40% coinsurance after deductible
Imaging (CT and PET scans, MRIs) Office/Non-hospital: 40% coinsurance after deductible
Outpatient Hospital: 40% coinsurance after deductible
Outpatient Mental Health Office visit: Virtual Connect Plus through selected providers, including Closeknit - No charge* no deductible (carefirst.com/virtualconnect) All other providers - $55 copay, no deductible
Outpatient Substance Abuse Office visit: Virtual Connect Plus through selected providers, including Closeknit - No charge* no deductible (carefirst.com/virtualconnect) All other providers - $55 copay, no deductible
Outpatient Rehabilitation Services (PT, OT, ST) Office/Non-hospital: $65 copay after deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Inpatient Coverage
Hospitalization Hospital charge: 40% coinsurance after deductible (waived if admitted);
Physician charge: 40% coinsurance after deductible
Skilled Nursing Facility 40% coinsurance after deductible
Inpatient Mental Health Hospital charge: 40% coinsurance after deductible (waived if admitted);
Physician charge: 40% coinsurance after deductible
Inpatient Substance Abuse Hospital charge: 40% coinsurance after deductible (waived if admitted);
Physician charge: 40% coinsurance after deductible
Home Healthcare No charge, no deductible
Maternity Coverage
Pre & Postnatal Office Visit Preventive: No charge, no deductible
Non-preventive: $55 copay, no deductible
Labor & Delivery Hospital Stay Hospital charge: 40% coinsurance after deductible (waived if admitted);
Physician charge: 40% coinsurance after deductible
Pediatric Services
Dental Checkup for Children No charge, no deductible
Vision Screening for Children No charge, no deductible
Eye Glasses for Children No charge, no deductible
Major Dental Coverage (Pediatric) Surgical: 20% coinsurance after dental deductible
Restorative: 50% coinsurance after dental deductible
Additional Coverage
Chiropractic Coverage Office/Non-hospital: $65 copay after deductible
Outpatient Hospital: (If service is rendered in a Hospital Facility, an additional facility charge my apply)
Durable Medical Equipment 30% coinsurance after deductible
Hospice No charge, no deductible
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Routine Eye Exam: No charge, no deductible
Out-of-Network Coverage
Out-of-Network Authorization Required No
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating NR as of 12/08/2025
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • CareFirst BlueCross BlueShield - Preferred Provider Organization (PPO) plans are underwritten by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc. Point of Service (POS) plans are underwritten by CareFirst BlueChoice Inc., for in-network benefits and by Group Hospitalization and Medical Services, Inc. or CareFirst of Maryland, Inc. for out-of-network benefits. Health Maintenance Organization (HMO) plans are underwritten by CareFirst BlueChoice, Inc.
  • CareFirst BlueCross BlueShield - Serving Maryland, the District of Columbia and portions of Virginia, CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. The Blue Cross and Blue Shield Names and Symbols are registered trademarks of the Blue Cross and Blue Shield Association.